On 21 April 2022, a pedestrian was struck and fatally injured by an out-of-service passenger train at the Lady Howard footpath and bridleway crossing near Ashtead.
The pedestrian, who was walking on the crossing with a dog and pushing a wheeled trolley bag, started to cross the railway tracks shortly after a train had passed. She was struck by a second train, which was travelling in the opposite direction to the first. The driver of the train involved in the accident sounded the train’s horn on seeing the pedestrian on the crossing. The pedestrian responded by hurrying towards the exit of the crossing but was unable to get clear of the path of the train in time to avoid being struck.
The report into RAIB’s original investigation was published on 14 February 2023. Subsequently, new evidence came to light and as a consequence, RAIB announced its intention to re-open the investigation on 15 August 2023.
RAIB’s investigation found that the pedestrian was apparently unaware that the second train was approaching when she made the decision to cross; there is no evidence that she was aware of it and/or had misjudged the time available to cross. This was because, although the pedestrian looked twice in the direction of the second train before starting to cross, the front of this second train was hidden behind the first train, which was moving away on the line nearest to her. RAIB also found it was possible that the pedestrian did not perceive the risk arising from the possibility that the first train was hiding another approaching train.
A probable underlying factor was that Network Rail had not provided any effective additional risk mitigation at the crossing despite having previously deemed the risk to users to be unacceptable. New evidence considered as part of the re-opened investigation indicated that, while Network Rail had planned and budgeted to install integrated miniature stop lights at the crossing to mitigate the risk to users, a shortage of resource meant that delivery of this system was delayed. Network Rail had not considered effective options to mitigate the risk on an interim basis while this installation was pending. It also had not considered applying for a derogation to an internal standard, which would have allowed it to fit a simpler version of the miniature stop light system at the crossing. RAIB found, however, that even had a derogation been obtained and the simpler version of the system been fitted, it is unlikely that it would have been operational before the accident took place.
As a result of its original investigation, RAIB made two recommendations to Network Rail. These remain unchanged in the revised report.
The first recommendation is intended to address the risk to pedestrians at crossings of this type arising from a second approaching train being hidden from view by another train. The second recommendation concerns the implementation of appropriate interim risk mitigations at level crossings that are awaiting long-term solutions.
As a result of the re-opened investigation, the revised report includes an important learning point about checking whether derogations from standards exist or could be applied for, as this may in some cases provide an opportunity to reduce risk in a more timely and cost-effective manner.